RARE GASTRIC CALCIFYING FIBROUS PSEUDOTUMOR REMOVED BY ENDOSCOPIC SUBMUCOSAL DISSECTION

We report a case of a calcifying fibrous pseudotumor of the stomach that we resected using endoscopic submucosal dissection (ESD). A 61‐year‐old male with a gastric submucosal tumor was admitted to our hospital for treatment. By upper gastrointestinal tract endoscopy, a smooth‐surfaced submucosal tumor measuring 2 cm in diameter was observed in the anterior wall of the middle body of the stomach. By endoscopic ultrasonography, a mass was observed in the stomach submucosa; the mass had a well‐defined boundary. Internally, the mass was heterogeneous and hypoechoic; high spots were scattered throughout the mass. Continuity between the mass and the muscularis mucosae and muscularis propria was not observed. Strongly suspecting that this mass was a gastrointestinal stromal tumor arising from the stomach, we resected the mass by ESD for total biopsy. Histopathologically, the mass consisted of proliferation of eosinophilic collagen fibers with plasma cell infiltration and lymphoid follicle proliferation. Calcification was also observed in some parts of the mass. Thus, the mass was identified as calcifying fibrous pseudotumor. Calcifying fibrous pseudotumor of the stomach is extremely rare and its histogenesis remains unclear; however, its morphology became distinct by comparing endoscopic/radiological and histopathological findings.     

内镜超声在消化道黏膜下肿瘤诊断与治疗中的价值

目的 评价内镜超声在消化道黏膜下肿瘤的诊断及治疗中的价值.方法 对内镜检查中怀疑黏膜下肿瘤者进行内镜超声检查,根据黏膜下肿瘤的起源层次及性质决定治疗方案,内镜治疗包括内镜下黏膜切除术、黏膜剥离-肿瘤摘除术、高频电切术及硬化治疗.结果 73例良性间质瘤起源于黏膜肌层,7例直肠类癌位于黏膜固有层;脂肪瘤13例、异位胰腺17例、胃底静脉曲张5例、囊肿6例起源于黏膜下层;95例良性间质瘤及21例恶性间质瘤起源于固有肌层,1例类癌侵及固有肌层.61例源于黏膜肌层及8例源于固有肌层的良性间质瘤、8例脂肪瘤、8例异位胰腺及7例类癌经内镜切除,4例囊肿行内镜下穿刺治疗;33例源于固有肌层的良性间质瘤、18例恶性间质瘤、2例脂肪瘤、2例异位胰腺及1例类癌经手术切除.病理符合率为97.97%.结论 超声内镜能够对消化道黏膜下肿瘤进行起源和定性诊断,对黏膜下肿瘤治疗方案的选择具有重要的指导意义.     

A case report of ball valve syndrome caused by the gastrointestinal stromal tumor arising from the muscularis mucosae in gastric fornix

An 83-year-old woman who was admitted to other hospital, was consulted us because of continuous tarry stool and abdominal fullness. On upper endoscopy, the submucosal tumor from greater curvature of gastric fornix invaginated into the duodenal bulbus, showing so-called "ball valve syndrome (BVS)". As the tumor incarcerted again on the following endoscoopy, she underwent laparoscopic partial gastrectomy. The submucosal tumor was diagnosed histologically as gastrointestinal stromal tumor (GIST) arising from the muscularis mucosae. This is the first report that GIST arising from the muscularis mucosae in gastric fornix showed a BVS.     

A case of giant esophageal leiomyoma successfully resected by endoscopic submucosal dissection followed by retrieval via laparotomy

A 30-year-old woman with chest discomfort at swallowing and occasional vomiting was referred to our department with a diagnosis of esophageal submucosal tumor. CT visualized a mass 70 mm in diameter in the middle esophagus. Esophagogastroduodenoscopy revealed a pedunculated submucosal tumor, and endoscopic resection was considered. As the size of the tumor was so large, retrieval of the resected specimen via the stomach following incision, laparotomy was planned. En bloc resection by endoscopic submucosal dissection with a Hook-knife was performed. Retrieval of the resected specimen was carried out as planned. The specimen, which was 53×48×43mm in size with a distinct margin, was diagnosed as leiomyoma derived from the muscularis mucosae histologically. Her postprocedural course was uneventful. Endoscopic resection can be chosen when an esophageal submucosal tumor is pedunculated with abundant mobility, making it possible to avoid invasive surgery.     

食管黏膜下肿物的特性以及超声内镜的诊断和治疗意义

背景：食管病变内镜下或手术治疗的风险均较高,术前准确判断病变的层次和性质,对决定手术的方式十分重要。目的：探讨食管黏膜下肿物的特性以及超声内镜对食管黏膜下肿物的诊断、治疗意义。方法：由内镜检查发现的116例食管黏膜下肿物患者行超声内镜检查,并给予相应的切除治疗,总结超声内镜下食管黏膜下肿物的特性。结果：超声内镜下88例（75．9％）食管黏膜下肿物的直径〈1cm,104例（89．7％）病变起源于黏膜肌层,多数（85．3％）表现为低回声或混合偏低回声的声像图。80例接受切除治疗,其中67例（83．8％）行EMR治疗,肿物直径〈1cm者占89．6％,局限于黏膜肌层占97．0％。组织病理学分析表明食管黏膜下肿物以平滑肌瘤最为常见（86．3％）。超声内镜诊断与病理诊断的符合率约为82％。结论：大多数食管黏膜肌层起源的肿物行EMR治疗简便、安全,对于较大的病灶,或起源于固有肌层者ESD仍是一种安全有效的方法。超声内镜可判断食管黏膜下肿物起源并进行定性诊断,从而指导临床合理选择黏膜下肿物的治疗方法。     

小探头内镜超声在消化道隆起性病变中的诊断价值

目的探讨小探头内镜超声扫查消化道黏膜下病变在管壁的分布特点以及对消化道黏膜下隆起性病变的诊断价值。方法回顾性分析2017年1月—2018年10月在武汉协和医院行小探头内镜超声检查消化道隆起性病变316例,患者均行内镜下治疗切除,组织送病理检查,通过超声检查结果结合病理诊断明确病变的层次和性质。结果316例消化道隆起性病变中黏膜下病变198例,其中平滑肌瘤118例,间质瘤27例,脂肪瘤、囊肿各15例,乳头状瘤4例,神经内分泌瘤7例,异位胰腺9例,颗粒细胞瘤、神经鞘瘤和布氏腺瘤各1例。病变分布在整个消化道管壁,以起源于黏膜肌层最常见,有7例病变在小探头内镜超声下未明确层次。结论小探头内镜超声可以明确黏膜下病变在消化道中的分布,并对病变大小、层次起源提供高准确率的判断,对治疗方案的选择亦有重要指导意义。     

Leiomyosarcoma of the stomach treated by endoscopic submucosal dissection

There have been no reports of primary leiomyosarcoma of the stomach treated by endoscopic submucosal dissection (ESD). We report an extremely rare case of gastric leiomyosarcoma that was successfully treated by ESD. An asymptomatic 74-year-old female underwent esophagogastroduodenoscopy for screening in December 2013. A centrally depressed submucosal tumor 10 mm in diameter was detected at the posterior wall of the upper gastric body. Follow-up esophagogastroduodenoscopy conducted 5 months later showed that the tumor diameter had increased to 15 mm. Endoscopic ultrasound revealed a hypoechoic mass located in the second to the middle of the third layer. Endoscopic ultrasound-guided fine-needle aspiration demonstrated a myogenic tumor. The tumor was completely resected by ESD without complications. Immunohistopathological diagnosis of the resected specimen was gastric leiomyosarcoma derived from the muscularis mucosae, with negative lateral and vertical margins. No local recurrence or metastasis has been detected at 36 months after ESD. This is the first report of gastric leiomyosarcoma treated by ESD in the English language literature.     

源于固有肌层的胃间质瘤行内镜下切除闭合术的可行性研究

目的 评价对来源于固有肌层的非腔内生长型胃间质瘤施行内镜下切除闭合术治疗的可行性.方法 46例患者经胃镜和超声内镜检查诊断为起源于固有肌层的非腔内生长型胃黏膜下肿瘤,采用内镜下切除闭合术切除肿瘤,行常规病理及免疫组化检查后证实为间质瘤.术后内镜随访,观察治疗效果及有无并发症.结果 46例非腔内生长型胃间质瘤经内镜下切除闭合术治疗后均完全切除,切除后2例保留完整的浆膜层,44例术中遗留切口,切口最大径1.5 cm,行钛夹夹闭切口,予抑酸、胃肠减压、静脉应用抗生素等辅助治疗.病理报告全层切除46例,肿瘤直径为0.5～3.7 cm.44例患者术后48～72 h后进食,未见明显不适;2例术后出现气腹、局限性腹膜炎,其中1例切口1.5 cm患者术后第2天切口裂开,再次钛夹夹闭裂开切口,辅助治疗10～12 d,该2例患者痊愈出院.术后6个月随访,所有患者切口均形成白色溃疡瘢痕.结论 对于非腔内生长型胃间质瘤,内镜下切除闭合术是一种安全、经济、创伤小的治疗方式,值得临床推广.     

内镜超声检查在上消化道黏膜下肿瘤微创治疗中的价值研究

目的评价超声内镜检查对上消化道黏膜下肿瘤的诊断价值及指导内镜下微创治疗黏膜下肿瘤的疗效及安全性。方法经超声内镜诊断上消化道黏膜下肿瘤82例,根据黏膜下肿瘤的起源层次、大小及性质分别选择不同的内镜治疗方案,内镜治疗包括高频电凝电切术、内镜下黏膜切除术、皮圈套扎术等。标本行常规病理学及免疫组化检查。术后定期内镜随访。结果26例超声判断起源于黏膜肌层的上消化道黏膜下肿瘤行高频电凝电切术;17例起源于黏膜肌层的平坦型上消化道黏膜下肿瘤行内镜下黏膜切除术;38例起源于固有肌层和1例起源于黏膜肌层的上消化道黏膜下肿瘤行皮圈套扎术。内镜超声诊断与术后病理符合率为91．4％。术后1例出血,其余无严重并发症发生。79例术后随访3—24个月无复发。结论超声内镜能够对消化道黏膜下肿瘤进行起源和定性诊断,超声内镜为内镜微创治疗选择消化道黏膜下肿瘤适应证具有良好的指导作用,内镜治疗是消化道黏膜下肿瘤治疗的安全、有效的手段。     

超声微探头在上消化道黏膜下隆起性病变中的诊断和指导治疗方式价值

目的探讨超声微探头在上消化道黏膜下隆起性病变中的诊断和治疗价值。方法对胃镜检查发现隆起性病变91例患者进行超声微探头检查,根据超声胃镜图像特点选择治疗方案;并对部分内镜治疗或手术切除病例进行超声微探头复查。结果发现外压性改变5例,黏膜下肿瘤86例,包括良性间质瘤50例,恶性间质瘤3例,浸润性癌5例,胃或食管癌手术后吻合口隆起8例,胃淋巴瘤1例,胃黏膜皱襞肥大2例,Brunner腺增生1例,脂肪瘤2例,异位胰腺2例,孤立性静脉瘤7例,静脉曲张4例,囊肿1例。28例黏膜肌层良性间质瘤和2例黏膜下层脂肪瘤采用胃镜下高频电凝切除,11例黏膜肌层间质瘤术后6个月超声微探头复查有3例在原切除部位见到残留的瘤体,胃或食管癌手术后吻合口隆起8例中4例复发并经病理学证实。结论超声微探头能显示黏膜下隆起病变的层次和性质,有利于治疗方案的选择和对治疗效果的评价,从而提高胃镜医师的诊断水平。     

上消化道固有肌层肿瘤的内镜治疗

目的探讨三种常见的内镜治疗方法对于起源于固有肌层的上消化道肿瘤的治疗价值。方法通过胃镜及超声内镜筛选出2011至2013年共70例患有上消化道固有肌层肿瘤的病例,根据肿瘤的位置及深度采用三种常见的内镜治疗方法给予切除。三种方法是:内镜黏膜下挖除术(ESE),内镜全层切除术(EFR),内镜经黏膜下隧道肿瘤切除术(STER)。切除肿瘤术后均经免疫组化及分子生物学等相关病理检测,检测指标为CD34、CD117、Dog-1、S-100、平滑肌肌动蛋白(SMA)、Ki-67以及核分裂数。结果共有35例患者接受ESE治疗,其中2例出现穿孔,通过钛夹修补;27例接受STER治疗,未出现穿孔并发症;8例接受EFR治疗,均有"人工"穿孔,通过钛夹完全修补。所有70例经过治疗后均完全康复,未追加外科手术治疗。结论上消化道固有肌层肿瘤可通过内镜治疗成功切除,可逐步替代外科手术治疗,且有更大的应用范围。     

Endoscopic enucleation of upper-GI submucosal tumors by using an insulated-tip electrosurgical knife

BACKGROUND: Submucosal tumors often are found incidentally at upper endoscopy. Although the majority of the ones less than 5 cm in size are benign, periodic monitoring for incremental changes in size, which can be stressful and bothersome to patients, is essential. If relatively easy and safe, an endoscopic method of removal would be optimal treatment. Conventional endoscopic enucleation technically is difficult and often leads to serious complications, such as bleeding and perforation. A novel method for endoscopic enucleation of submucosal tumors with an insulated-tip electrosurgical knife is reported. METHODS: En bloc enucleation was attempted by using an insulated-tip electrosurgical knife in 15 patients (10 men, 5 women; median age 48 years) with submucosal tumors of the esophagus (5) or stomach (5 cardia/fundus, 4 body, one antrum). EUS was performed to determine the layer of origin and the exact size of the submucosal tumor. RESULTS: Tumors arose in the muscularis propria in 11 cases, submucosa in two, and muscularis mucosa in one. Enucleation was relatively easy and successful in 14 cases. In one case, however, piecemeal resection was unavoidable because of fibrotic adhesions with the surrounding tissue; this tumor later was confirmed to be a glomus tumor. Median procedure time was 35 minutes (8-180 minutes) and median size of the submucosal tumors was 2x1.7 cm. The largest lesion, located in the esophagus, measured 6x3 cm. Histopathologic diagnoses included leiomyoma (9), GI stromal tumor (4), stromal tumor of unknown malignant potential (1), and glomus tumor (1). A small perforation occurred in one patient with a 2.5-cm tumor in the anterior wall of proximal gastric body but was managed successfully by endoscopic clip application. Follow-up endoscopy at 2 months in this patient revealed no tumor recurrence and complete healing of the treatment-related ulcer. CONCLUSIONS: En bloc endoscopic enucleation of submucosal tumors by using an insulated-tip electrosurgical knife appears to be safer, easier, and less time consuming compared with previously described methods. However, further investigation and comparative studies are required to confirm the safety and efficacy of this method.     

SOLITARY PEDUNCULATED GASTRIC GLAND HETEROTOPIA TREATED BY ENDOSCOPIC POLYPECTOMY: REPORT OF A CASE

The patient, a 68‐year‐old woman with a long‐standing history of schizophrenia, was admitted to our hospital complaining of vomiting which had lasted approximately 3 weeks. Endoscopic examination of the stomach revealed a solitary pedunculated submucosal tumor, of approximately 2 cm in diameter, on the anterior wall of the upper body, close to the greater curvature. The lesion was endoscopically excised using a polypectomy snare without any complication. Microscopic examination was compatible with the diagnosis of gastric gland heterotopia showing submucosal proliferation of pseudopyloric glands, fundic glands and foveolar epithelium with fibromuscular stromal framework. The proliferating foveolar epithelium and fibromuscular stroma were in continuity with the overlaying gastric mucosa and muscularis mucosae, respectively. The lesion was entirely covered by normal gastric epithelium. No atypical cells were revealed in the lesion. The clinical significance of gastric gland heterotopia is unclear because of its controversial histogenesis and carcinogenetic potential. We herein report a rare case of solitary pedunculated gastric gland heterotopia with some review of scientific reports.     

Primary minute invasive de novo colonic adenocarcinoma appearing as submucosal tumor

A 4 mm white-yellow submucosal tumor-like lesion was detected in the sigmoid colon of an asymptomatic 52-yr-old Japanese man. Because the lesion was unexpectedly suspicious for adenocarcinoma by pathological examination of the biopsy specimen, it was treated by endoscopic mucosal resection. The specimen obtained demonstrated well-differentiated adenocarcinoma without any adenomatous element, and was located principally in the submucosal layer with a maximum depth of 1600 mum from the muscularis mucosae. The cancer exposed to the luminal surface was pathologically concluded to be diminutive. Intriguingly, aggregation of lymphocytes was found beneath the mucosal layer, which might have compromised the integrity of the muscularis mucosae. Because of deep submucosal infiltration and the latent aggressive nature of de novo cancer, the patient underwent an additional partial sigmoidcolectomy, which demonstrated no residual cancer and no regional lymph node metastasis. The lesion in this patient exhibited a previously undescribed appearance of de novo colon cancer as submucosal tumor in an early phase of growth.     

Polypoid leiomyosarcoma of the esophagus treated by endoscopic submucosal dissection

We report a rare case of polypoid leiomyosarcoma of the esophagus that was treated by endoscopic submucosal dissection (ESD). A 63‐year‐old man with complaints of progressive dysphagia was referred to Hyogo Cancer Center for treatment of esophageal tumor. Esophagoscopy revealed a polypoid tumor 25 mm in diameter on the left side of the upper esophagus. Despite several biopsy specimens, the diagnosis could not be confirmed. Computed tomography showed a protruded, homogeneously enhancing mass in the upper esophagus, but no lymph node enlargement or metastasis. After 1.5 months, the esophagogram showed a filling defect 47 mm in diameter in the upper esophagus. Given this rapid tumor growth, en bloc resection was done by ESD for therapeutic diagnosis. After this treatment, the tumor seemed to grow larger, showing a short stalk and occupying the esophageal lumen. Histopathologically, the tumor comprised pleomorphic spindle cells with mitosis. Tumor invasion involved the lumina propria mucosae and contact with the muscularis mucosae, but not involving the submucosa. Immunohistochemical examination showed positive staining for smooth muscle actin and HHF35, but negative for desmin, caldesmon, CD34, c‐kit, DOG1, ALK, S‐100 protein and cytokeratin. These histopathological findings were compatible with a diagnosis of esophageal leiomyosarcoma derived from the muscularis mucosae.     

消化道黏膜下肿物的内镜及超声内镜下特点分析

目的探讨消化道黏膜下肿物的内镜及超声内镜下特点。方法对153例消化道黏膜下肿物进行内镜及超声内镜检查,最终经病理学及免疫组化明确诊断。结果确诊消化道平滑肌瘤51例、胃肠道间质瘤37例、脂肪瘤30例、类癌21例、异位胰腺7例、神经鞘瘤3例、错构瘤3例和血管球瘤1例。超声内镜对平滑肌瘤、间质瘤、脂肪瘤、类癌、异位胰腺、神经鞘瘤、错构瘤和血管球瘤的诊断符合率分别为92%、92%、100%、71%、71%、0、0和100%,其总诊断符合率为86%,明显高于内镜总诊断符合率(70%)。结论超声内镜可明确消化道黏膜下肿物的大小、起源、回声、生长方式,对消化道黏膜下肿物的诊断及鉴别诊断有重要作用。     

Value of endoscopic ultrasonography for upper gastrointestinal stromal tumors: a single center experience.

BACKGROUND/AIMS: Gastrointestinal stromal tumors are the rarely seen tumors of the gastrointestinal tract. The aim of the present study was to review the patients diagnosed as upper gastrointestinal stromal tumor by endoscopic ultrasonography. METHODS: Twenty-five patients diagnosed as upper gastrointestinal stromal tumor, between 1999 and 2004, were reviewed retrospectively. RESULTS: The reason for performing upper gastrointestinal system endoscopy was nonspecific upper gastrointestinal system symptoms in most (76%) of the patients. The other causes were upper gastrointestinal bleeding and dysphagia in 16% and 8% of the cases, respectively. Lesions were located in the stomach in 17 (68%), in the esophagus in six (24%), and in the duodenum in two (8%) patients. Endoscopic ultrasonographic evaluation revealed that all of the lesions arose from the muscularis propria. In 18 (72%) patients, tumors were less than 3 cm in diameter, homogeneous and hypoechoic in appearance with regular borders, concordant with benign tumor. In five (20%) patients, lesions had heterogeneous echoic appearance with anechoic spaces, two of which were larger than 3 cm and also showed irregular borders, suggesting malignancy. Surgical therapy was performed in five (20%) patients because of upper gastrointestinal bleeding or suspicion of malignancy by endoscopic ultrasonographic evaluation. Histopathological examination confirmed the diagnosis in all these patients. CONCLUSIONS: Endoscopic ultrasonographic evaluation is very useful in diagnosis and for choosing the therapeutic method for patients with upper gastrointestinal stromal tumor.     

经胃镜保留浆膜层切除上消化道固有肌层起源肿瘤技术初探

目的 探讨经内镜浆膜下肿瘤切除术（ESSD）对上消化道黏膜下肿瘤切除的安全性及有效性。方法 收集2016年10月至2017年2月在南京鼓楼医院接受ESSD的6例黏膜下肿瘤患者资料,分析手术时间、手术成功率、术后病理、并发症等。结果 纳入的6例患者均完整切除肿瘤,其中1例患者发生浆膜面穿孔。肿瘤平均大小（27.5±10.0）mm,手术平均耗时（49±18）min。术后病理均提示为低危险度间质瘤。6例患者均顺利出院,未发生严重并发症。结论 ESSD作为一种新兴的内镜下治疗方法,对固有肌层起源肿瘤安全可靠。     

内镜黏膜下挖除术治疗食管固有肌层肿瘤

目的探讨内镜黏膜下挖除术（ESE）治疗食管固有肌层肿瘤的临床价值。方法回顾性分析2008年12月至2010年12月27例行ESE治疗的食管固有肌层肿瘤患者的资料,评价治疗的可行性、安全性和疗效。结果27例患者共29个病灶,病变直径0．5—3．0cm,平均（1．25±0．70）cm。切除率96．3％（26／27）,1例患者中转手术治疗。中位手术时间74（30～120）min。术后病理诊断平滑肌瘤26例,间质瘤1例。2例术中穿孔伴气胸,金属夹夹闭创面后予胸腔闭式引流,未行开胸手术修补。中位随访时间12（3～27）个月,未见复发病例。结论对于直径小于3．0cm、腔内生长为主的食管固有肌层肿瘤,ESE治疗具有安全、有效的特点,并可提供完整的病理学诊断资料,进一步扩大了内镜治疗的范围。     

Endoscopic Muscularis Excavation for Subepithelial Tumors of the Esophagogastric Junction Originating from the Muscularis Propria Layer

Background

Because of complicating anatomic factors, endoscopic submucosal dissection is seldom performed in subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer.

Aim

This study was designed to evaluate the feasibility of endoscopic muscularis excavation for treating subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer.

Methods

Between December 2008 and December 2011, 68 patients with subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer were treated with endoscopic muscularis excavation. Key steps of the procedure included the following: (1) injecting a mixture solution into the submucosal layer after making several dots around the tumor; (2) making a cross incision of the overlying mucosa, and excavating the tumor from the muscularis propria layer; (3) closing the artificial ulcer with clips after tumor removal.

Results

The mean tumor size was 16.2 mm (range 7–35 mm). Endoscopic muscularis excavation was successfully performed in 65 out of 68 cases (success rate 95.6 %). Pathological diagnosis of these tumors included leiomyoma (39 out of 68) and gastrointestinal stromal tumor (29 out of 68). Perforation occurred in seven patients (10.3 %). No massive bleeding or delayed bleeding occurred. The median follow-up period after the procedure was 23 months (range 6–42 months). No residual or recurrent tumor was detected and no stricture occurred in patients during the follow-up period.

Conclusions

Endoscopic muscularis excavation is a safe, effective and feasible procedure for providing accurate histopathologic evaluation and curative treatment for subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer.